<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444414178
Report Date: 06/13/2025
Date Signed: 06/13/2025 11:28:01 AM

Document Has Been Signed on 06/13/2025 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KIM, NICOLEFACILITY NUMBER:
444414178
ADMINISTRATOR/
DIRECTOR:		KIM, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 332-9872
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY: 14TOTAL ENROLLED CHILDREN: 24CENSUS: 12DATE:
06/13/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nicole KimTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On June 13, 2025, Licensing Program Analyst (LPA) Darnella Barnes conducted an unannounced annual inspection. The purpose was explained to the licensee, who granted access. and received the Entrance Checklist (LIC 126).

The facility operates Monday – Friday 8:00am to 5:30pm.. Required postings were visible, and the last fire/disaster drill was on 5/21/25, The licensee was reminded of the six-month drill and documentation requirement.

Licensee, two Assistants, three infants, and nine preschoolers, meeting capacity and ratio requirements. LPA observed Assistants were engaged, attentive and interacted appropriately with the children circle time, singing songs, reading a book, and other interactive activities.

Licensee was provided information and reminded of capacity and ratio rules, supervision requirements, reporting obligations, and that children’s rights cannot be waived.

Licensee was also reminded that children showing signs of illness should be separated from others until it is determined whether they are contagious. They must remain separated until they are no longer infectious or are picked up.

All adults 18 and older associated with the facility, including residents and volunteers,must have fingerprint clearances.

---CONTINUED ON NEXT PAGES----.

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, NICOLE
FACILITY NUMBER: 444414178
VISIT DATE: 06/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Childcare Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA toured the facility’s indoor areas, the off-limit areas include all of the second floor, kitchen, family room, garage and laundry room The home was clean, well ventilated, and has safe toys, play equipment and materials. A fully charged 2A-10-BC fire extinguisher, was last serviced on 1/1/25, is available, along with working smoke and carbon monoxide detectors, and an operating telephone. All hazardous items, including poisons, detergents, cleaning compounds, and medicines were kept out of children’s reach. The home was free of defects or dangers that could harm a child. Licensee was reminded that smoking is prohibited. Licensee has a fireplace located in the living room, which is off limits area. The licensee understands that although the fireplace is in an off-limits area, it will not be used during day care hours. Licensee confirmed there are no guns, firearms, ammunition on the property. .

Outdoor off limits area include side of house BBQ section which is gated separately for safety for children. Licensee understands that outdoor play areas must either be fenced or, if no fence is present, children must be supervised at all times. The outdoor play area is fenced and has age-appropriate toys for the children such as sandbox, tricycles, slides and cars. There was no bodies of water. Licensee was reminded to notify licensing before making any changes to the house or yard.

Licensee CPR/First Aid expires 4/3/26 with mandatory training expiring 2/14/27. Assistant (A1) CPR/First Aid expires 8/10/26 and mandatory training expiring 10/16/25. Assistant (A2) mandatory training expiring 7/12/26. LPA reminded the licensee of the two-year renewal requirement. LPA advised the applicant that if liability insurance is not provided or the daycare is not named in the policy, parents must sign the Affidavit Regarding Liability Insurance (LIC 282) and file it in each child's record. Licensee does have insurance covering the child care.


---CONTINUED ON NEXT PAGES ----
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, NICOLE
FACILITY NUMBER: 444414178
VISIT DATE: 06/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility roster and five children’s files were reviewed, confirming all required forms were complete. The licensee does not transport children. Licensee was reminded that should license elect to transport children that licensee must have current driver’s license, that children cannot be left unattended in vehicles and that car seats and booster seats must be available for safe transportation.

Safe Sleep Information was provided, and licensee was reminded that an Individual Infant Sleeping Plan (LIC 9227) is a required for each infant up to 12 months old, with nap checks documented until age two. Cribs and play yards must be free of loose items, bumper pads, and hanging objects and mattresses must be firm, properly fitted, and have fitted sheets. Additionally baby walkers, bouncers, jumpers, and similar items are not allowed.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was reminded Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, inspection the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care- licensing/subscribe and select the Child Care option to receive email communication.



Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (8004314-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/
---CONTINUED ON NEXT PAGE ---
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, NICOLE
FACILITY NUMBER: 444414178
VISIT DATE: 06/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California. Car seats and booster seats must be available for safe transportation.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please inspection the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.



During the exit interview, the Licensee confirmed no Registered Sex Offenders reside at the facility. The LPA completed the RSO profile in FAS on 4/29/25. A search of the California Attorney General-Megan’s Law website found no registered sex offenders at the facility address.

No deficiency issued during today's inspection. Appeals rights provided.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Nicole Kim




---END OF REPORT ----
NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Darnella Barnes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5